TEACHING MODULE: by XD8k2NW

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									TEACHING MODULE:
   CANCER UNIT
    WINTER 2011
     HIM 253




 BY: AMIE DENNIS
       Within the HIM field there are some subjects that are not as popular or
well known as others. One such subject is Cancer Registry. In order to try to
understand cancer registry we have to go back to the basics. We need to define
what cancer is and how it forms. In the body there are normal cells that grow and
divide to produce more cells. When the cells get damaged they die and are
replaced with new cells. Sometimes, the damaged or mutated cells don’t die, but
the body still produces new cells. The extra cells form a mass of tissue called a
tumor. Some cancers do not form tumors, instead the bad cells infiltrate in to the
blood or immune system.

        One thing to remember is that not all tumors are cancerous. Tumors can
be benign or malignant. Benign tumors are not cancerous and can be removed,
generally without coming back. Malignant tumors are cancerous. Sometimes
cells from the tumor invade nearby tissue and spread to other parts of the body.
This spreading of cells is called metastasis.

       When talking about cancer, there are generally 5 classes of cancer. They
are carcinoma, sarcoma, leukemia, lymphoma, myeloma and central nervous
system cancers. Carcinoma is cancer that begins in the skin or tissue that lines
or covers internal organs. Sarcoma is cancer that begins in bone, cartilage, fat,
muscle, blood vessels or other connective or supportive tissues. Leukemia is a
cancer that starts in blood-forming tissue such as bone marrow and causes large
numbers of abnormal blood cells to be produced. Lymphoma and myeloma are
cancers that begin in the cells of the immune system. Central nervous system is
cancer that begins in the tissue of the brain or spinal cord.

       As part of the cancer registry process, cancer staging is a very important
step. Cancer staging is describing the severity of a person’s cancer. It is based
on the extent of the original tumor and whether or not the cancer has spread
throughout the body. A couple of reasons staging is important are a) it helps the
provider plan the appropriate treatment, b) knowing the stage can help estimate
the prognosis of the patient, c) it helps researchers and healthcare providers
exchange information about patients and their cancer.

       There are 5 common elements of the staging system. First is the site of
the primary tumor. A primary tumor is the point of origin where the tumor started.
Second is tumor size and number of tumors. Third is the involvement of lymph
nodes. Fourth is cell type and tumor grade. Tumor grade is how closely the
cancer cells resemble normal tissue cells. The fifth and last common element of
staging is the presence or absence of metastasis.
       There are several well known staging systems. One commonly used
system is the TNM staging system. The TNM system is divided in to three distinct
parts.

          o Primary Tumor (T)

                 1. TX- primary tumor cannot be evaluated

                 2. T0- no evidence of primary tumor

                 3. Tis- Carcinoma in situ (Carcinoma in situ is an early form of
                    carcinoma that is absent of invasion of the surrounding
                    areas)

                 4. T1, T2, T3, T4- size and/or extent of primary tumor: 1-small,
                    2-medium, 3-large, 4-extra large

          o Regional Lymph Nodes (N)

                 1. NX- regional lymph nodes cannot be evaluated

                 2. N0- no regional lymph node involvement

                 3. N1, N2, N3- Involvement of regional lymph nodes (the
                    number of lymph nodes and/or extent of spreading to the
                    lymph nodes)

          o Distant Metastasis

                 1. MX- distant metastasis cannot be evaluated

                 2. M0- no distant metastasis

                 3. M1- distant metastasis is present


        There are five stages of cancer. Stage 0 is carcinoma in situ. Stages I, II,
III which indicate the extent of the cancer. The higher the number, the more
extensive the cancer. Stage IV indicates that cancer has spread to other organs.
Not all cancers are classified by the TNM system. Cancers of the brain and
spinal cord are staged according to their cell type and grade.

Many cancer registries use another staging system, called the summary staging.
This staging system groups cancer in to five categories.
Cancer Registry Summary
A cancer register collects, stores, summarizes, and distributes information about
cancer patients. A patient is called a case in cancer registry. The data collected
describe the patient and the disease. Patient demographic information, cancer
identification, diagnostic procedures, cancer treatment and survival are the
pieces of data that are collected. This information that is collected helps benefit
the patient, medical professionals and the community.

       There are 6 main functions of a cancer registry. Those functions are:

           1. Case Finding: Remember that a case is a patient. This function
              identifies reportable cases. Reportable cases are ones that are not
              in situ or have invasive malignancies.

           2. Abstracting: Use the medical record to identify and document
              information, in a standard manner, about the patient and their
              disease.

           3. Follow-up: The registry continues to monitor patient’s health status
              for their lifetime, at periodic intervals.

           4. Quality Control: The accuracy and completeness of registry data is
              monitored.

           5. Reporting: Analyzing data and distributing information using the
              registry database.

           6. Organizing and participating in cancer program activities. This
              participation could be in educational efforts and screening
              programs.

       There are two basic types of cancer registries. The first is a hospital-based
registry. This type of registry is tailored to a specific hospital. The facility’s cancer
committee has required data that must be collected on the cases. The hospital
also must collect data according to the state registry. The second is a central
registry. This registry is a little more specialized. Childhood cancer registries and
population based registries are two examples of a central registry.
Case Finding
       In order to find cases for a registry, the registrar has to look at path reports
as well as consultations from specialists. They have to read the path report to
look for any terminology that would suggest the patient has cancer. Sometimes,
a patient may have more than one primary cancer site. When a patient has more
than one, they are not entered in the computer twice, instead it is added upon the
information already in the registry about that patient.

Abstracting a Record
      Abstracting of a chart happens when the patient is done with treatment or
they have died. Abstracting is when the registrar takes information from the
medical chart and puts it in to the patient’s file in the registry. Back before there
were computers this process was done with index cards. Some of the things that
need to be abstracted are patient demographics, information about the cancer
such as primary site, whether it metastasized, and any treatment that was given.

Follow Up
       Follow up in cancer registry is an important step. As part of the survey
process every year, the percentage of follow up needs to be 90% or higher. This
means that at least 90% of the cancer patients in the registry need to have
followed up with a doctor within the past 6 months to a year. There are several
ways to find this information. One way is to look in the patient’s chart and see
when they were last seen by a provider. Another way is a website put on by Fred
Hutch Cancer Center. The website is called Cancer Surveillance System. On this
website you can find out when the patient was last seen for the treatment of
cancer. It also will tell you if the patient is alive or deceased. The follow up helps
researches see what the life span is of someone with cancer.

Quality Control
       There are edit checks on the registry system. These allow you to see if
you entered information in the system correctly and if you are missing any vital
information. It is important to have quality information in the registry as it is used
for research purposes. The more accurate the information the more accurately
they can come up with clinical trials for different types of cancer.
Reporting
       All cancer cases need to be reported to FHCRC (Fred Hutch Cancer
Research Center). FHCRC is ultimately responsible for submitting all cancer
cases to the state. Once cases are sent to FHCRC they do edit checks on the
cases. They check things such as treatment information and dates, appropriate
cancer with the sex of the patient and first date of contact versus last date of
contact. Once the edit checks have been done, it is the responsibility of the
cancer registrar to go back in and fix the errors and resubmit them to FHCRCC.
The CSS website is where the cases are uploaded to. This website also runs
reports for the facilities. The reports are anything from the top 24 cancer sites to
the number of new cases per year.

Organizing and Participating in Cancer Program Activities
         There are two main components to cancer programs; tumor board and
cancer committee. Tumor board is a group of doctors that meet to discuss cancer
cases. The cases they present are usually rare, difficult or just cases that the
doctor feels needs to be presented. One physician presides over the meeting. He
starts by giving a brief synopsis of the case. Then he lets the physician who is
treating that patient talk about the patient’s history and physical. Next, the
radiologist talks about different scans the patient has had. After the radiologist,
the pathologist shows slides of the cells of the tumor. Once all the information is
given about the case, they go over the NCCN (National Comprehensive Cancer
Network) guidelines and make sure they are following the guidelines. Then they
go over possible treatments for the patient. Usually the cancer registrar for that
facility puts together the tumor board. They make handouts that have the cases
on them. They get together with drug reps to have lunch provided for the
physicians. They then document the tumor board findings in the patient’s cancer
registry file.

       Cancer committee is a group of physicians, nursing administrators,
diagnostic and therapeutic specialists, allied health professionals and
representatives from ancillary services. Usually there is also someone from the
cancer registry present. They meet four times a year. Some of the things they
discuss are: community outreach programs, clinical research programs,
educational events, quality of cancer care outcomes, and disease and treatment
specific performance measures.
Introduction to the ICD-O book
        While we are used to using the ICD-9 coding book, in 1976 the first edition
of ICD-O was published. ICD-O stands for International Classification of
Diseases for Oncology. This new classification system was published by the
WHO. There are a couple of terms in the ICD-O book that I would like to go over.
The first is topography. Topography means the description of anatomic regions
or sites of the body. In situ tumors are confined to a place of origin and they have
not left the membrane of the tissue involved. The ICD-O uses a four digit
topographic category for coding the site of the tumor. This is based on the
Malignant Neoplasm section of the ICD-9. There is also a six digit morphology
code for the histology of tumors.

       In 1990 a new edition of the ICD-O was published. This was titled
 ICD-O-2. This new edition is based on ICD-10. The new edition had changes to
the topographic categories as well as the morphology section. Also, in this new
addition a new section was added. The new section contains Non-Hodgkin’s
Lymphoma. ICD-O-2 is broken down in to five parts. Those parts being a)
Introduction and Instructions for Use of ICD-O, Second Edition, b)Topography, c)
Morphology, d) Alphabetic Index and e) New Morphology Terms and Synonyms.


SUMMARY
In this module we have learned about cancer and cancer registry. We learned
what cancer is and the different classes of cancer such as carcinoma, sarcoma
and leukemia. The next part that we learned about was cancer registry and the
different steps that cancer registrars make. One such step is case finding. We
also touched a little bit on the ICD-O book, which is the coding manual for
cancer. The information we learned is important as the first step in your goal of
progressing in your cancer registry career.
                          Citations

     http://seer.cancer.gov/training/manuals/Book2.pdf

          http://seer.cancer.gov/training/manuals/

   http://seer.cancer.gov/tools/codingmanuals/index.html

          http://seer.cancer.gov/icd-o-3/index.html

http://www.state.nj.us/health/ces/documents/njscr_manual.pdf

     http://seer.cancer.gov/training/manuals/Book5.pdf

    Connie Grace- Valley Medical Center Cancer Registry
                                 Cancer Unit

                                 Assignment 1
Instructions: Code each case study. Each question is worth 5 points.

   1. Gracie Sue is a 45 year old female. She came in to see Dr Merryweather
      for a lump in her breast. Dr Merry weather performed a biopsy. When the
      pathology came back it showed she had breast cancer that had spread
      outside the breast to 2 nearby lymph nodes but not to other parts of the
      body. Use the TNM system to code the breast cancer.




   2. Edgar Williams is a 65 year old male who came in to see Dr Oh because
      of some pain in his prostate area. Dr Oh did a biopsy of the prostate.
      When the pathology came back it showed he had prostate cancer and it
      had not spread to any lymph nodes or any other part of the body. This was
      the primary tumor site. Use the TNM system to code the prostate cancer.




   3. Molly is an 18 year old female who came in to see Dr Gin for an abnormal
      pelvic ultrasound. It was determined Molly had a large tumor and they
      needed to biopsy it in order to figure out what treatment to give her. When
      the pathology came back it showed bladder cancer that did not involve
      any lymph nodes and had not metastasized. Use the TNM system to code
      the bladder cancer and state what stage the cancer is in.
                                 Cancer Unit
                                 Assignment 2
Instructions: Answer each question. Each question is worth 2 points

   1. Most cancers in the world are carcinomas. ○True ○ False

   2. Mr. Jones went in for a routine physical. Upon examination the doctor
      found a tumor on his thigh. When asked about it, Mr. Jones said that it had
      been slowly enlarging over the past 5 years. Apparently there was no
      evidence of invasion or metastases. The tumor probably is:
      ○ a) Malignant

      ○ b) Benign

      ○ c) can’t say

   3. Ms. Margaret was diagnosed as having colon and liver cancer. The liver
      was called a metastatic site. Where in the body did the liver cancer start?


   4. When metastasis occurs, we know that the cancer has spread from the
      ______ ______, and a secondary site is invaded by cancer.


   5. Sometimes the name of a tumor will describe the type of cells involved. 55
      year old Mike Pool has a malignant tumor that arose in his glandular
      tissue. What would this type of cancer be called?
      ○ a) Epithelioma

      ○ b) Adenocarcinoma

      ○ c) Myeloma
Match the following malignancies with whether it is carcinoma or sarcoma.

             Malignancy                  Type of
                                         Cancer

       6. Cancer of the colon

        7. Gallbladder cancer

   8. Cancer of the skin of the lip

      9. Malignant bone tumor

 10. Malignancy of the thigh muscle

             A. Sarcoma

             B. Carcinoma

             C. Carcinoma

             D. Sarcoma

             E. Carcinoma


   11. An alphanumeric system of categories means a mixture of letters of the
   alphabet and numeric digits. ○True ○ False

   12. Chapter 3 of ICD-9 is for neoplasms. ○ True ○ False

   13. NOS stands for Never Otherwise Stated. ○ True ○ False

   14. The ICD-O-2 Manual has two main sections: Topography and
   Morphology. ○ True ○ False

   15. The principal change from the ICD-O to ICD-O-2 is the addition of the
   Non-Hodgkin’s Lymphoma section. ○ True ○ False
                                   Cancer Unit
                                   Assignment 3

Part One:
Instructions: Read the attached medical record and, using the abstract form
provided, enter in the information on the abstract form. Worth 25 points.

                        Cancer Abstract
                            Form
   Demographics



  Patient Name             Date of Birth              Social Security Number


       Address at time of diagnosis                     City, State, Zip Code


       Sex                 Marital Status

        Tumor
     Information
  The following information identifies the type and location of cancer with which
 your patient was diagnosed. Please provide complete and accurate information
  on the type and location of cancer for each patient's abstract. Please submit a
                           pathology report if available.


                                                     This is the anatomical location of
 1. Primary site                                  tumor origin. Be careful not to record
                                                   the metastatic site. Also include the
                                                                  laterality.




                                            Record histologic type including the grade
2. Histologic type of this cancer           or degree of differentiation as stated in the
                                             FINAL path report. If a report designates
                                                            two degrees
3. Date cancer first diagnosed      Please include month, day, century
                                                 and year

                                                     Page 1 of 4

                                   Please record the initial month, day,
4. Initial visit for this cancer    century, and year that this patient
                                      was seen in the office with this
                                            cancer diagnosis



                                   Please record the last date of contact
                                      with this patient. If the patient is
5. Date of last contact               deceased please record date of
                                                    death.




                                   The TNM Classification is based on
                                   the evaluation of the primary tumor
6. TNM classification               (T), regional lymph nodes (N), and
                                   distant metastasis (M). Stage Group
                                                (Stage 0-4).




                                      Record the largest dimension or
                                      diameter of the primary tumor in
7. Tumor size                        millimeters. For melanoma of the
                                     skin, please record the depth and
                                               thickness also.




                                   Record the date, name and results of
8. Tumor markers                    any tumor marker studies that have
                                               been done.




9. LDH serum results               Record the results of the LDH assay
                          Please record clinical assessment of
10. Clinical lymph node      lymph nodes prior to definitive
status of diagnosis                    treatment




 Treatment Information


                           Please indicate whether the patient
11. Did this patient      has received or is currently receiving
receive any                  any treatment for this cancer. If
treatment for this         treatment was or is currently being
cancer?                   received, please specify the type and
                              date treatment was initiated.




                           Record the date and type of cancer-
                             directed surgery performed. An
                           excisional biopsy is cancer-directed
                            surgery. Review the operative and
12. Surgery               pathology report and record surgical
                          procedures performed. If performing
                            melanoma excision or re-excision
                          record whether margins are negative
                          and if margins are greater than 1 cm.




                          Record the date, type, amount, and
13. Radiation             duration of radiation administered to
                             the primary or metastatic site.
                            Record the date, type and duration of
                              chemotherapy administered to the
                             patient. Record the generic or trade
14. Chemotherapy                   names of drugs used for
                             chemotherapy. Record combination
                                    therapy abbreviations.




                            Record the date, type and duration of
15. Hormone/other therapy    therapy administered to the patient.




                              If the patient has been referred to
                              another physician for treatment of
                            this cancer, please provide the name
16. Referral to                of the hospital and/or physician.
                                 Please include the physician's
                               address, phone number and fax
                                            number.
Date of Colonoscopy: 10-15-2010
Date of Initial visit with Oncology: 11-01-10
Date of last visit with Oncology: 1-15-11
Date of Surgery: 11-26-10
Date of Treatment: 12-10-10
                                Quiz
                             Cancer Unit

Match each term with its definition. Each answer is worth 2 points.

  Term (A, B, C)         Definition (1, 2, 3) Answer (1A, 3F, 4J)
      A. Staging           1. A group of
                           physicians that get
                           together and discuss
                           treatment for
                           different cancer
                           patients

  B. Carcinoma in situ     2. The description of
                           anatomic regions or
                           sites of the body

    C. Primary Site        3. Identifies
                           reportable cases

  D. Cancer Registry       4. Site where the
                           first tumor was found

    E. Case Finding        5. Describing the
                           severity of a
                           person’s cancer

     F. Abstracting        6. The spreading of
                           cancer cells to other
                           parts of the body

    G. Topography          7. Collects, stores,
                           summarizes and
                           distributes
                           information about
                           cancer patients
H. Metastasis    8. When damaged
                 cells don’t die, the
                 body still produces
                 new cells. The extra
                 cells form this.

I. Tumor Board   9. Using the medical
                 record to identify and
                 document
                 information about
                 the patient and their
                 cancer

  J. Cancer      10. an early form of
                 carcinoma that is
                 absent of invasion of
                 the surrounding
                 areas
                                      Exam
                                    Cancer Unit

Instructions: There are 5 multiple choice, 5 fill in the blank, 5 true/false, and 5
staging questions. Each question is worth 5 points.

Multiple choice:

1. Cancer staging is:

○ A) a performance by cancer on the main stage
○ B) describes the severity of a person’s cancer based on the extent of the
primary tumor and whether or not it has spread throughout the body.
○ C) the type of primary tumor

2. The 5 common elements of the staging system are:

 A) Primary tumor, tumor size and number of tumors, involvement of lymph
nodes, cell type and tumor grade, presence or absence of metastasis
 B) Primary tumor, length of tumor, girth of tumor, presence or absence of
metastasis, involvement of lymph nodes
 C) Involvement of lymph nodes, primary tumor, location of tumor, color of
tumor, presence or absence of metastasis
 D) Presence or absence of metastasis, color of tumor, date of tumor discovery,
primary tumor, tumor shape

3. A tumor board:
○ A) is a place where tumors are placed after they are removed
○ B) is a group of physicians who review cancer charts to decide the best course
of treatment for that patient
○ C) A bar that they stick inside the tumor to get rid of it
○ D) A group of cancer registrars who decide the course of treatment for a
patient

4. Colon cancer is a form of:
○ A) Melenoma
○ B) Carcinoma
○ C) Sarcoma
○ D) Sigmoidoma

5. The principal change from the ICD-O to ICD-O-2 is the addition of
○ A) the brain cancer section
○ B) the lung cancer section
○ C) the colon cancer section
○ D) the Non-Hodgkin’s Lymphoma section.
Fill in the blank:

1. How does cancer form? ________________________

2. When metastasis occurs, we know that the cancer has spread from the
 ______ ______, and a secondary site is invaded by cancer.

3. Ms. Margaret was diagnosed as having colon and liver cancer. The liver was
called a metastatic site. Where in the body did the liver cancer start?

4.What does NOS stand for?

5.What year was the new ICD-O published?

True/False:

1. There are 10 stages of cancer.  True  False
2. Carcinoma in situ refers to the cancer being spread throughout the body.
 True  False
3. Height and weight are part of the abstract form.  True  False
4. The ICD-O is the International Classification of Oncology.  True  False
5. Abstracting is the use of the medical record to identify and document
information, in a standard manner, about the patient and their disease.
 True  False



Staging questions:
Please give the TNM code.

   1. Rebecca has a small tumor in her colon, does not involve any lymph
      nodes and has not metastasized. It is carcinoma in situ.
   2. David has a medium tumor in his liver. It started in his lungs. It involves 3
      lymph nodes. It metastasized from his lungs to his liver.
   3. Bonnie has a small tumor in her pancreas. It involves 2 lymph nodes. It
      has not metastasized.
   4. Mary has an extra large tumor in her liver. It started in her colon and has
      also spread to her pancreas. It involves 3 lymph nodes. It has
      metastasized.
   5. Donald has a small tumor in his stomach. It involves 1 lymph node and
      has not metastasized.
                                Answer Key
                                Cancer Unit

Assignment 1:
   1. T1N2M0
   2. TisN0M0
   3. T3N0M0

Assignment 2:
   1. True
   2. B
   3. Colon
   4. Primary Site
   5. B
   6. B, C, E (any of these)
   7. B, C, E (any of these)
   8. B, C, E (any of these)
   9. A, D (either one)
   10. A, D (either one)
   11. True
   12. False
   13. False
   14. False
   15. True

Quiz:
1. I                    2. G
3. E                    4. C
5. A                    6. H
7. D                    8. J
9. F                    10. B
   Exam:
1. B                        2. A
3. B                        4. B
5.D

1. Damaged cells don’t      2. Primary Site
die off and new cells are
made. The extra cells
form a mass of tissue
called a tumor.
3. colon                    4. Not otherwise specified
5.1990

1. False                    2. False
3. False                    4. True
5. True

1. Tis N0 M0                2. T2 N3 M1
3. T1 N2 M0                 4. T4 N3 M1
5.T1 N1 M0
                          Cancer Abstract Form
   Demographics

     Bobby Dolittle                3/16/1953                                            222-18-6912
                                    Date of
         Name                         Birth                                        Social Security Number

             2575 W 25th                                                            Tacoma, WA 98405
      Address at time of diagnosis                                                  City, State, Zip Code

               Married                 Male
               Marital
               Status                   Sex


Tumor Information
                   The following information identifies the type and location of cancer with which
                  your patient was diagnosed. Please provide complete and accurate information
                   on the type and location of cancer for each patient's abstract. Please submit a
                                            pathology report if available.

                                      This is the anatomical location of tumor origin. Be careful not to record the
1. Primary Site                                        metastatic site. Also include the laterality.

                                                         Colon

                                                       Record histologic type including the grade or degree of
                                                    differentiation as stated in the FINAL path report. If a report
2. Histologic type of this cancer                                      designates two degrees

                               Adenocarcinoma, Grade G2, moderately differentiated


3. Date cancer first diagnosed                                         Please include month, day, century and year
                                                      10/15/2010



                                                                        Please record the initial month, day, century,
                                                                         and year that this patient was seen in the
4. Initial visit for this cancer                                              office with this cancer diagnosis
                                                       11/1/2010



                                                                         Please record the last date of contact with
                                                                       this patient. If the patient is deceased please
5. Date of last contact                                                              record date of death.
                                                1/15/2011



                                                                  The TNM Classification is based on the
                                                                evaluation of the primary tumor (T), regional
                                                               lymph nodes (N), and distant metastasis (M).
6. TNM classification                                                    Stage Group (Stage 0-4).

                                             T3 N1 stage III



                                                               Record the largest dimension or diameter of
                                                                  the primary tumor in millimeters. For
                                                                melanoma of the skin, please record the
7. Tumor size                                                           depth and thickness also.
                                                  3.5cm




                                                                 Record the date, name and results of any
                                                                tumor marker studies that have been done.
8. Tumor markers                                                          For example the CEA.

                                                CEA 1.9


9. LDH serum results                                               Record the results of the LDH assay

                                              not available




10. Clinical lymph node status                                  Please record clinical assessment of lymph
of diagnosis                                                        nodes prior to definitive treatment

                                    2 out of 36 lymph nodes involved


  Treatment Information




                                                                 Please indicate whether the patient has
                                                                   received or is currently receiving any
11. Did this patient                                          treatment for this cancer. If treatment was or
receive any treatment                                        is currently being received, please specify the
for this cancer?                                                  type and date treatment was initiated.
                         Yes, he received chemotherapy. He started on 12-10-10.
                                                                    Record the date and type of cancer-directed
                                                                     surgery performed. An excisional biopsy is
                                                                        cancer-directed surgery. Review the
                                                                     operative and pathology report and record
                                                                    surgical procedures performed. If performing
                                                                      melanoma excision or re-excision record
                                                                    whether margins are negative and if margins
12. Surgery                                                                     are greater than 1 cm.

                                       Right hemicolectomy on 11-26-10.



                                                                    Record the date, type, amount, and duration
                                                                     of radiation administered to the primary or
13. Radiation                                                                      metastatic site.

                                                      None




                                                                       Record the date, type and duration of
                                                                     chemotherapy administered to the patient.
                                                                    Record the generic or trade names of drugs
                                                                    used for chemotherapy. Record combination
14. Chemotherapy                                                               therapy abbreviations.

 Start date is 12-10-10. 48 hour infusion, every 14 days for 6 months. Folinic acid, fluorouracil, and oxaliplatin
                 (FOLFOX) which is a combination of 5-fluorouracil, leucovorin and oxaliplatin.



                                                                    Record the date, type and duration of therapy
15. Hormone/other therapy                                                   administered to the patient.

                                                      None
                                        If the patient has been referred to another
                                       physician for treatment of this cancer, please
                                          provide the name of the hospital and/or
                                         physician. Please include the physician's
16. Referral to                          address, phone number and fax number.

                  Dr Daniels in Puyallup

								
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